Stewart W. Mercer

Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study

BACKGROUND Long-term disorders are the main challenge facing health-care systems worldwide, but health systems are largely configured for individual diseases rather than multimorbidity. We examined the distribution of multimorbidity, and of comorbidity of physical and mental health disorders, in relation to age and socioeconomic deprivation. METHODS In a cross-sectional study we extracted data on 40 morbidities from a database of 1,751,841 people registered with 314 medical practices in Scotland as of March, 2007. We analysed the data according to the number of morbidities, disorder type (physical or mental), sex, age, and socioeconomic status. We defined multimorbidity as the presence of two or more disorders. FINDINGS 42·2% (95% CI 42·1-42·3) of all patients had one or more morbidities, and 23·2% (23·08-23·21) were multimorbid. Although the prevalence of multimorbidity increased substantially with age and was present in most people aged 65 years and older, the absolute number of people with multimorbidity was higher in those younger than 65 years (210,500 vs 194,996). Onset of multimorbidity occurred 10-15 years earlier in people living in the most deprived areas compared with the most affluent, with socioeconomic deprivation particularly associated with multimorbidity that included mental health disorders (prevalence of both physical and mental health disorder 11·0%, 95% CI 10·9-11·2% in most deprived area vs 5·9%, 5·8%-6·0% in least deprived). The presence of a mental health disorder increased as the number of physical morbidities increased (adjusted odds ratio 6·74, 95% CI 6·59-6·90 for five or more disorders vs 1·95, 1·93-1·98 for one disorder), and was much greater in more deprived than in less deprived people (2·28, 2·21-2·32 vs 1·08, 1·05-1·11). INTERPRETATION Our findings challenge the single-disease framework by which most health care, medical research, and medical education is configured. A complementary strategy is needed, supporting generalist clinicians to provide personalised, comprehensive continuity of care, especially in socioeconomically deprived areas. FUNDING Scottish Government Chief Scientist Office.

Adapting clinical guidelines to take account of multimorbidity

Care of patients with multimorbidity could be improved if new technology is used to bring together guidelines on individual conditions and tailor advice to each patient’s circumstances, say Bruce Guthrie and colleagues

An exploratory mixed methods study of the acceptability and effectiveness of mindfulness -based cognitive therapy for patients with active depression and anxiety in primary care

BackgroundMindfulness Based Cognitive Therapy (MBCT) is an 8-week course developed for patients with relapsing depression that integrates mindfulness meditation practices and cognitive theory. Previous studies have demonstrated that non-depressed participants with a history of relapsing depression are protected from relapse by participating in the course. This exploratory study examined the acceptability and effectiveness of MBCT for patients in primary care with active symptoms of depression and anxietyMethods13 patients with recurrent depression or recurrent depression and anxiety were recruited to take part in the study. Semi-structured qualitative interviews were conducted three months after completing the MBCT programme. A framework approach was used to analyse the data. Beck depression inventories (BDI-II) and Beck anxiety inventories (BAI) provided quantitative data and were administered before and three months after the intervention.ResultsThe qualitative data indicated that mindfulness training was both acceptable and beneficial to the majority of patients. For many of the participants, being in a group was an important normalising and validating experience. However most of the group believed the course was too short and thought that some form of follow up was essential. More than half the patients continued to apply mindfulness techniques three months after the course had ended. A minority of patients continued to experience significant levels of psychological distress, particularly anxiety.Statistically significant reductions in mean depression and anxiety scores were observed; the mean pre-course depression score was 35.7 and post-course score was 17.8 (p = 0.001). A similar reduction was noted for anxiety with a mean pre-course anxiety score of 32.0 and mean post course score of 20.5 (p = 0.039). Overall 8/11 (72%) patients showed improvements in BDI and 7/11 (63%) patients showed improvements in BAI. In general the results of the qualitative analysis agreed well with the quantitative changes in depression and anxiety reported.ConclusionThe results of this exploratory mixed methods study suggest that mindfulness based cognitive therapy may have a role to play in treating active depression and anxiety in primary care.

The Inverse Care Law: Clinical Primary Care Encounters in Deprived and Affluent Areas of Scotland

PURPOSE The inverse care law states that the availability of good medical care tends to vary inversely with the need for it in the population served, but there is little research on how the inverse care law actually operates. METHODS A questionnaire study was carried out on 3,044 National Health Service (NHS) patients attending 26 general practitioners (GPs); 16 in poor areas (most deprived) and 10 in affluent areas (least deprived) in the west of Scotland. Data were collected on demographic and socioeconomic factors, health variables, and a range of factors relating to quality of care. RESULTS Compared with patients in least deprived areas, patients in the most deprived areas had a greater number of psychological problems, more long-term illness, more multimorbidity, and more chronic health problems. Access to care generally took longer, and satisfaction with access was significantly lower in the most deprived areas. Patients in the most deprived areas had more problems to discuss (especially psychosocial), yet clinical encounter length was generally shorter. GP stress was higher and patient enablement was lower in encounters dealing with psychosocial problems in the most deprived areas. Variation in patient enablement between GPs was related to both GP empathy and severity of deprivation. CONCLUSIONS The increased burden of ill health and multimorbidity in poor communities results in high demands on clinical encounters in primary care. Poorer access, less time, higher GP stress, and lower patient enablement are some of the ways that the inverse care law continues to operate within the NHS and confounds attempts to narrow health inequalities.

Multimorbidity in primary care: developing the research agenda

Multimorbidity usually defined as the co-existence of two or more long-term conditions in an individual is the norm rather than the exception in primary care patients 1,2 and will become more prevalent as populations age. 3,1 Multimorbidity cuts across the vertical paradigms in which most health research and policy is envisaged, supported and carried out, reflecting not only specialist interests in particular problems and diseases, but also the tendency of research to focus on easily defined issues. ‘‘Complicated’’ patients with multimorbidity are usually excluded from such research. Although complexity is under-represented in the research literature, it is common place in general medical practice, where the challenges are ‘‘horizontal’’, integrating not only at the level of the clinical encounter, but also in the co-ordination of services to support patients with multiple problems. The challenge of carrying out research on multimorbidity is to reflect, investigate, inform and improve these aspects of generalist clinical practice. Given that multimorbidity is a challenge facing practitioners and patients alike it has attracted surprisingly little research interest. 4 The research to date has largely focussed on analysis of the impact of multimorbidity on individuals and healthcare systems, with very few studies examining interventions to improve outcomes. One of ‘multimorbidity’s many challenges’ includes setting a research agenda to systematically begin to answer important practical issues in supporting people with multimorbidity. Given the scale and complexity of the task, the first difficulty is simply knowing where to start. In order to gather views from the academic primary care community on the research agenda in multimorbidity we held workshops in Ireland (July 2008) and Scotland (January 2009) under the aegis of the Society for Academic Primary Care and the Scottish School of Primary Care respectively. The workshops were attended by approximately 50 delegates, including patient representatives, primary care professionals, and academics; both explored issues of definition, outcome measures, studies and interventions. The common themes that emerged are outlined below.

The effect of physical multimorbidity, mental health conditions and socioeconomic deprivation on unplanned admissions to hospital: a retrospective cohort study

Background: Multimorbidity, the presence of more than 1 long-term disorder, is associated with increased use of health services, but unplanned admissions to hospital may often be undesirable. Furthermore, socioeconomic deprivation and mental health comorbidity may lead to additional unplanned admissions. We examined the association between unplanned admission to hospital and physical multimorbidity, mental health and socioeconomic deprivation. Methods: We conducted a retrospective cohort study using data from 180 815 patients aged 20 years and older who were registered with 40 general practices in Scotland. Details of 32 physical and 8 mental health morbidities were extracted from the patients’ electronic health records (as of Apr. 1, 2006) and linked to hospital admission data. We then recorded the occurrence of unplanned or potentially preventable unplanned acute (nonpsychiatric) admissions to hospital in the subsequent 12 months. We used logistic regression models, adjusting for age and sex, to determine associations between unplanned or potentially preventable unplanned admissions to hospital and physical multimorbidity, mental health and socioeconomic deprivation. Results: We identified 10 828 (6.0%) patients who had at least 1 unplanned admission to hospital and 2037 (1.1%) patients who had at least 1 potentially preventable unplanned admission to hospital. Both unplanned and potentially preventable unplanned admissions were independently associated with increasing physical multimorbidity (for ≥ 4 v. 0 conditions, odds ratio [OR] 5.87 [95% confidence interval (CI) 5.45–6.32] for unplanned admissions, OR 14.38 [95% CI 11.87–17.43] for potentially preventable unplanned admissions), mental health conditions (for ≥ 1 v. 0 conditions, OR 2.01 [95% CI 1.92–2.09] for unplanned admissions, OR 1.80 [95% CI 1.64–1.97] for potentially preventable unplanned admissions) and socioeconomic deprivation (for most v. least deprived quintile, OR 1.56 [95% CI 1.43–1.70] for unplanned admissions, OR 1.98 [95% CI 1.63–2.41] for potentially preventable unplanned admissions). Interpretation: Physical multimorbidity was strongly associated with unplanned admission to hospital, including admissions that were potentially preventable. The risk of admission to hospital was exacerbated by the coexistence of mental health conditions and socioeconomic deprivation.

Drug-disease and drug-drug interactions: systematic examination of recommendations in 12 UK national clinical guidelines

Objective To identify the number of drug-disease and drug-drug interactions for exemplar index conditions within National Institute of Health and Care Excellence (NICE) clinical guidelines. Design Systematic identification, quantification, and classification of potentially serious drug-disease and drug-drug interactions for drugs recommended by NICE clinical guidelines for type 2 diabetes, heart failure, and depression in relation to 11 other common conditions and drugs recommended by NICE guidelines for those conditions. Setting NICE clinical guidelines for type 2 diabetes, heart failure, and depression Main outcome measures Potentially serious drug-disease and drug-drug interactions. Results Following recommendations for prescription in 12 national clinical guidelines would result in several potentially serious drug interactions. There were 32 potentially serious drug-disease interactions between drugs recommended in the guideline for type 2 diabetes and the 11 other conditions compared with six for drugs recommended in the guideline for depression and 10 for drugs recommended in the guideline for heart failure. Of these drug-disease interactions, 27 (84%) in the type 2 diabetes guideline and all of those in the two other guidelines were between the recommended drug and chronic kidney disease. More potentially serious drug-drug interactions were identified between drugs recommended by guidelines for each of the three index conditions and drugs recommended by the guidelines for the 11 other conditions: 133 drug-drug interactions for drugs recommended in the type 2 diabetes guideline, 89 for depression, and 111 for heart failure. Few of these drug-disease or drug-drug interactions were highlighted in the guidelines for the three index conditions. Conclusions Drug-disease interactions were relatively uncommon with the exception of interactions when a patient also has chronic kidney disease. Guideline developers could consider a more systematic approach regarding the potential for drug-disease interactions, based on epidemiological knowledge of the comorbidities of people with the disease the guideline is focused on, and should particularly consider whether chronic kidney disease is common in the target population. In contrast, potentially serious drug-drug interactions between recommended drugs for different conditions were common. The extensive number of potentially serious interactions requires innovative interactive approaches to the production and dissemination of guidelines to allow clinicians and patients with multimorbidity to make informed decisions about drug selection.

An ‘endless struggle’: a qualitative study of general practitioners’ and practice nurses’ experiences of managing multimorbidity in socio-economically deprived areas of Scotland:

Objectives: To understand general practitioners’ (GPs) and practice nurses’ (PNs) experiences of managing multimorbidity in deprived areas and elicit views on what might help. Methods: Qualitative interviews with 19 GPs and PNs in four practices with a high percentage of patients living in the top 15% most deprived areas of Scotland. Data were analysed using constant comparison. Results: Professionals’ discussions of how they managed multimorbidity captured: (1) definitions of multimorbidity that included multiple social, psychological, and health problems associated with deprivation; (2) descriptions of the ‘endless struggle’ of patients trying to manage illnesses in the midst of chaotic lives with limited personal, social, and material resources; (3) accounts of the ongoing struggle of professionals trying to manage, with personal consequences for some; and (4) ideas on what might help, including ‘whole person’ approaches. Discussion: Professionals’ discussions of the difficulties that they face personally and attempt to help those most in need reflect both the continuing existence of the ‘inverse care law’ and the need for whole system changes to enhance the effectiveness of primary care for patients with multimorbidity in deprived areas.

Schizophrenia is associated with excess multiple physical-health comorbidities but low levels of recorded cardiovascular disease in primary care: cross-sectional study

Objective To assess the nature and extent of physical-health comorbidities in people with schizophrenia and related psychoses compared with controls. Design Cross-sectional study. Setting 314 primary care practices in Scotland. Participants 9677 people with a primary care record of schizophrenia or a related psychosis and 1 414 701 controls. Main outcome measures Primary care records of 32 common chronic physical-health conditions and combinations of one, two and three or more physical-health comorbidities adjusted for age, gender and deprivation status. Results Compared with controls, people with schizophrenia were significantly more likely to have one physical-health comorbidity (OR 1.21, 95% CI 1.16 to 1.27), two physical-health comorbidities (OR 1.37, 95% CI 1.29 to 1.44) and three or more physical-health comorbidities (OR 1.19, 95% CI 1.12 to 1.27). Rates were highest for viral hepatitis (OR 3.98, 95% CI 2.81 to 5.64), constipation (OR 3.24, 95% CI 3.00 to 4.49) and Parkinsons disease (OR 3.07, 95% CI 2.42 to 3.88) but people with schizophrenia had lower recorded rates of cardiovascular disease, including atrial fibrillation (OR 0.62, 95% CI 0.51 to 0.73), hypertension (OR 0.71, 95% CI 0.67 to 0.76), coronary heart disease (OR 0.75, 95% CI 0.61 to 0.71) and peripheral vascular disease (OR 0.83, 95% CI 0.71 to 0.97). Conclusions People with schizophrenia have a wide range of comorbid and multiple physical-health conditions but are less likely than people without schizophrenia to have a primary care record of cardiovascular disease. This suggests a systematic under-recognition and undertreatment of cardiovascular disease in people with schizophrenia, which might contribute to substantial premature mortality observed within this patient group.

Managing patients with mental and physical multimorbidity

Changes are needed in policy, research, and practice